How Much You Know About Valvular Heart Disease? Trivia Quiz

1. A 30-year-old woman presents for a routine checkup. She has no complaints and denies previous medical problems. On heart examination, the patient has a loud S1. She has a low-pitched mid-to-late diastolic murmur that is heard best at the apex. Immediately preceding the murmur is a loud extra sound. Which of the following is the most likely diagnosis?

Mitral valve prolapsed

Mitral stenosis

Ventricular septal defect

Aortic insufficiency

The most likely diagnosis in this case is mitral stenosis. Mitral stenosis is characterized by a low-pitched mid-to-late diastolic murmur that is heard best at the apex. The loud S1 and the presence of a loud extra sound immediately preceding the murmur are also consistent with mitral stenosis. Mitral valve prolapse, ventricular septal defect, and aortic insufficiency would not typically present with these findings.

Explanation

The most likely diagnosis in this case is mitral stenosis. Mitral stenosis is characterized by a low-pitched mid-to-late diastolic murmur that is heard best at the apex. The loud S1 and the presence of a loud extra sound immediately preceding the murmur are also consistent with mitral stenosis. Mitral valve prolapse, ventricular septal defect, and aortic insufficiency would not typically present with these findings.

2. The lesion shown in PICTURE below was observed at autopsy of a 35-year-old African American male, intravenous drug user who died 3 days after an acute febrile illness. What laboratory test finding is most likely to be found in the patient's medical record?

Elevated anti-streptolysin–O titer

High serum c-ANCA titer

High p-ANCA titer

Positive culture for Staphylococcus aureus

The given scenario describes a patient who died after an acute febrile illness, and the lesion observed at autopsy suggests an infection. The most likely finding in the patient's medical record would be a positive culture for Staphylococcus aureus, indicating that the patient had a Staphylococcus aureus infection. The other options, such as elevated anti-streptolysin-O titer, high serum c-ANCA titer, and high p-ANCA titer, are not specifically related to Staphylococcus aureus infection and are less likely to be found in this patient's medical record.

Explanation

The given scenario describes a patient who died after an acute febrile illness, and the lesion observed at autopsy suggests an infection. The most likely finding in the patient's medical record would be a positive culture for Staphylococcus aureus, indicating that the patient had a Staphylococcus aureus infection. The other options, such as elevated anti-streptolysin-O titer, high serum c-ANCA titer, and high p-ANCA titer, are not specifically related to Staphylococcus aureus infection and are less likely to be found in this patient's medical record.

3. A 32-year-old male who has been diagnosed as having aortic stenosis secondary to a bicuspid aortic valve develops classical angina pectoris after running 1.5 miles on uphill terrain. He consults a physician who confirms the diagnosis and determines that on examination his BP is 140/60 mmHg, and the patient has a harsh systolic ejection murmur radiating to the neck accompanied by a diastolic murmur compatible with associated aortic regurgitation. What is the mechanism for his chest pain most likely to be?

Supply/demand imbalance

Undiagnosed coronary artery disease

Abnormal diastolic blood pressure

Increased ventricular compliance

Low O2 saturation

The mechanism for his chest pain is most likely to be a supply/demand imbalance. This is because aortic stenosis, which the patient has, restricts blood flow from the heart to the rest of the body, leading to inadequate oxygen supply to the myocardium. During exercise, the demand for oxygen by the heart increases, but the stenotic aortic valve cannot deliver enough oxygenated blood to meet this demand. This results in chest pain, known as angina pectoris. The symptoms are aggravated during exercise due to the increased demand for oxygen.

Explanation

The mechanism for his chest pain is most likely to be a supply/demand imbalance. This is because aortic stenosis, which the patient has, restricts blood flow from the heart to the rest of the body, leading to inadequate oxygen supply to the myocardium. During exercise, the demand for oxygen by the heart increases, but the stenotic aortic valve cannot deliver enough oxygenated blood to meet this demand. This results in chest pain, known as angina pectoris. The symptoms are aggravated during exercise due to the increased demand for oxygen.

4. This patient presents to you office for a physical exam. Blood pressure is 145/88. Your exam findings include a bispherians carotid pulse as well as a high frequency diastolic decrescendo murmur (aortic area) with an apical diastolic rumble. The most likely cause would be:

Aortic stenosis

Mitral stenosis

Tricuspid regurgitation

Aortic regurgitation

WHY are his briefs on backwards??????

About half of the cases of aortic insufficiency are due to the aortic root dilatation (annuloaortic ectasia), which is idiopathic in over 80% of cases, but otherwise may result from aging, syphilitic aortitis, osteogenesis imperfecta, aortic dissection, Behçet's disease, reactive arthritis and systemic hypertension.[2] In about 15% the cause is innate bicuspidal aortic valve, while another 15% cases are due to retraction of the cusps as part of postinflammatory processes of endocarditis in rheumatic fever and various collagen vascular diseases. Additionally, aortic insufficiency has been linked to the use of some medications, specifically medications containing fenfluramine or dexfenfluramine isomers and dopamine agonists.

Other potential causes that affects the valve directly include:

*******MARFAN'S SYNDROME, **********Ehlers–Danlos syndrome, ankylosing spondylitis and systemic lupus erythematosus. In acute cases of aortic insufficiency, the main causes are infective endocarditis ,aortic dissection or trauma.

Explanation

WHY are his briefs on backwards??????

About half of the cases of aortic insufficiency are due to the aortic root dilatation (annuloaortic ectasia), which is idiopathic in over 80% of cases, but otherwise may result from aging, syphilitic aortitis, osteogenesis imperfecta, aortic dissection, Behçet's disease, reactive arthritis and systemic hypertension.[2] In about 15% the cause is innate bicuspidal aortic valve, while another 15% cases are due to retraction of the cusps as part of postinflammatory processes of endocarditis in rheumatic fever and various collagen vascular diseases. Additionally, aortic insufficiency has been linked to the use of some medications, specifically medications containing fenfluramine or dexfenfluramine isomers and dopamine agonists.

Other potential causes that affects the valve directly include:

*******MARFAN'S SYNDROME, **********Ehlers–Danlos syndrome, ankylosing spondylitis and systemic lupus erythematosus. In acute cases of aortic insufficiency, the main causes are infective endocarditis ,aortic dissection or trauma.

5. A 74-year-old Caucasian female presents to her family physician for evaluation of recurrent episodes of chest pain, shortness of breath with exertion, and lightheadedness. Two weeks earlier she experienced an episode of syncope while walking up the stairs of her house. Doppler ultrasonography reveals a heavily calcified aortic valve. The image below represents gross appearance of the patient's heart. Which of the following is the most likely diagnosis?

Aortic stenosis of rheumatic heart disease etiology

Aortic stenosis of luetic etiology

Aortic stenosis after subacute bacterial endocarditis

Calcific stenosis of congenitally bicuspid valve

Senile calcific aortic stenosis

The most likely diagnosis for this patient is senile calcific aortic stenosis. This is supported by the patient's age (74 years old) and the presence of heavily calcified aortic valve on Doppler ultrasonography. Senile calcific aortic stenosis is a common degenerative condition that occurs with aging, leading to narrowing of the aortic valve and symptoms such as chest pain, shortness of breath, and lightheadedness. The other options, such as aortic stenosis of rheumatic heart disease etiology, aortic stenosis of luetic etiology, aortic stenosis after subacute bacterial endocarditis, and calcific stenosis of congenitally bicuspid valve, are less likely given the patient's age and clinical presentation.

Explanation

The most likely diagnosis for this patient is senile calcific aortic stenosis. This is supported by the patient's age (74 years old) and the presence of heavily calcified aortic valve on Doppler ultrasonography. Senile calcific aortic stenosis is a common degenerative condition that occurs with aging, leading to narrowing of the aortic valve and symptoms such as chest pain, shortness of breath, and lightheadedness. The other options, such as aortic stenosis of rheumatic heart disease etiology, aortic stenosis of luetic etiology, aortic stenosis after subacute bacterial endocarditis, and calcific stenosis of congenitally bicuspid valve, are less likely given the patient's age and clinical presentation.

6. A 30 year old woman presents for a routine checkup. She has no complaints and denies previous medical problems. On heart examination, the patient has a loud S₁. She has a low-pitched mid-to-late diastolic murmur that is heard best at the apex. Immediately preceding the murmur is a loud extra sound. Which of the following is the most likely diagnosis?

Aortic stenosis

Mitral valve prolapsed

Ventricular septal defect

Aortic insufficiency

Mitral stenosis

Upon auscultation of an individual with mitral stenosis, the first heart sound is unusually loud and may be palpable (tapping apex beat) because of increased force in closing the mitral valve.

An opening snap which is a high pitched additional sound may be heard after the A2 (aortic) component of the second heart sound (S2), which correlates to the forceful opening of the mitral valve.

A mid-diastolic rumbling murmur with presystolic accentuation will be heard after the opening snap. The murmur is best heard at the apical region and is not radiated. Since it is low-pitched it is heard best with the bell of the stethoscope.

Explanation

Upon auscultation of an individual with mitral stenosis, the first heart sound is unusually loud and may be palpable (tapping apex beat) because of increased force in closing the mitral valve.

An opening snap which is a high pitched additional sound may be heard after the A2 (aortic) component of the second heart sound (S2), which correlates to the forceful opening of the mitral valve.

A mid-diastolic rumbling murmur with presystolic accentuation will be heard after the opening snap. The murmur is best heard at the apical region and is not radiated. Since it is low-pitched it is heard best with the bell of the stethoscope.

7. A 34-year-old Caucasian male is brought to the emergency room with shortness of breath and heart palpitations. His past medical history is significant for a ventricular septal defect. Physical examination reveals cyanosis, pitting edema of the lower legs, distended jugular veins, and hepatosplenomegaly. Heart examination reveals harsh holosystolic murmur and thrill at the left sternal border. Which of the following complications has most likely developed in this patient?

Eisenmenger syndrome

Atrial fibrillation

Ventricular fibrillation

Myocardial infarction

The patient's presentation of cyanosis, pitting edema, distended jugular veins, and hepatosplenomegaly, along with a ventricular septal defect and a harsh holosystolic murmur and thrill at the left sternal border, is consistent with Eisenmenger syndrome. Eisenmenger syndrome is a complication of congenital heart defects, such as a ventricular septal defect, where there is a reversal of shunt flow due to increased pulmonary vascular resistance. This leads to cyanosis and the development of right-sided heart failure. Therefore, Eisenmenger syndrome is the most likely complication in this patient.

Explanation

The patient's presentation of cyanosis, pitting edema, distended jugular veins, and hepatosplenomegaly, along with a ventricular septal defect and a harsh holosystolic murmur and thrill at the left sternal border, is consistent with Eisenmenger syndrome. Eisenmenger syndrome is a complication of congenital heart defects, such as a ventricular septal defect, where there is a reversal of shunt flow due to increased pulmonary vascular resistance. This leads to cyanosis and the development of right-sided heart failure. Therefore, Eisenmenger syndrome is the most likely complication in this patient.

8. A 56-year-old Caucasian man presents with recurrent precordial pain and frequent episodes of lightheadedness, muscle weakness and feeling faint. The patient reports that the symptoms first occurred three years ago and then gradually progressed. Physical examination reveals a heart rate of 88 bpm, BP of 130/69 mm Hg, a systolic "thrill" at the second right intercostal space, S4, and diminished S2 and crescendo-decrescendo systolic murmur over the aorta. What type of carotid pulse is most likely to be found in this patient?

Pulsus alternans

Pulsus parvus and tardus

Pulsus paradoxus

Pulsus bigeminus

pulsus tardus et parvus, also pulsus parvus et tardus, slow-rising pulse and anacrotic pulse, is a sign where, upon palpation, the pulse is weak/small (parvus), and late (tardus) relative to its usually expected character.

It is seen in aortic valve stenosis.

Typical findings in aortic stenosis include a narrow pulse pressure, left ventricular hypertrophy, a harsh late-peaking systolic murmur heard best at the right second intercostal space with radiation to the carotid arteries, and a delayed slow-rising carotid upstroke (pulsus parvus et tardus).[

Explanation

pulsus tardus et parvus, also pulsus parvus et tardus, slow-rising pulse and anacrotic pulse, is a sign where, upon palpation, the pulse is weak/small (parvus), and late (tardus) relative to its usually expected character.

It is seen in aortic valve stenosis.

Typical findings in aortic stenosis include a narrow pulse pressure, left ventricular hypertrophy, a harsh late-peaking systolic murmur heard best at the right second intercostal space with radiation to the carotid arteries, and a delayed slow-rising carotid upstroke (pulsus parvus et tardus).[

9. A 44-year-old woman with no known past medical history except for a "heart murmur" noticed in her early teenage years, has a sudden onset of "crushing substernal chest pain, radiating to the back". She then becomes severely hypotensive and unresponsive. What is the most likely diagnosis?

Mitral valve prolapsed

Rheumatic fever

Calcific degeneration of mitral valve

Congenital bicuspid aortic valve

Ventricular septal defect

Congenital bicuspid aortic valve
Aortic valve composed of 2 cusps instead of 3
Results from fusion of two cusps into one during development
May show systolic murmur in early life
Clinical complications:
Aortic stenosis
AORTIC DISSECTION

Explanation

Congenital bicuspid aortic valve
Aortic valve composed of 2 cusps instead of 3
Results from fusion of two cusps into one during development
May show systolic murmur in early life
Clinical complications:
Aortic stenosis
AORTIC DISSECTION

10. You have been seeing a 2-year-old female child at your clinic who has Tetralogy of Fallot. The parents are concerned because she has often been seen taking a "squatting" position on the floor multiple times per day. Since you know this is normal behavior, how do you explain it to the parents?

It prevents blood from flowing out of the heart causing it to go into the lungs

It changes the flow of electrical current in the heart

It prevents blood from flowing into the liver where it may pool

It decreases the flow of blood returning to the heart

It causes more blood to be shunted to the brain

The squatting position that the child takes helps to relieve the symptoms of Tetralogy of Fallot. This condition involves a combination of heart defects that result in decreased blood flow to the lungs. By squatting, the child increases the resistance in the blood vessels in the legs, which helps to prevent blood from flowing out of the heart too quickly. This allows more blood to flow into the lungs, improving oxygenation and relieving symptoms.

Explanation

The squatting position that the child takes helps to relieve the symptoms of Tetralogy of Fallot. This condition involves a combination of heart defects that result in decreased blood flow to the lungs. By squatting, the child increases the resistance in the blood vessels in the legs, which helps to prevent blood from flowing out of the heart too quickly. This allows more blood to flow into the lungs, improving oxygenation and relieving symptoms.

11. You are presented with the following findings

The most likely complication found in this patient is/are:

Myocarditis

Septic emboli

Non-septic emboli

Myocardial infarction

Rupture of myocardium

Bacterial Endocarditis:
Major complications
Destruction/rupture of valve
Heart failure
Valve insufficiency
*Septic emboli to other organs and tissues*
Splinter hemorrhages
Janeway lesions/Osler nodes
Roth's spots
Kidney abscesses
Brain infarcts

(middle picture of palm) *Janeway lesion*
non-painful hemorrhagic lesions on palms and soles of feet
*essentially diagnostic of bacterial endocarditis

Histology
Inflammation
Bacterial colonies
Staphylococcus aureus
Pseudomonas aeruginosa

Explanation

Bacterial Endocarditis:
Major complications
Destruction/rupture of valve
Heart failure
Valve insufficiency
*Septic emboli to other organs and tissues*
Splinter hemorrhages
Janeway lesions/Osler nodes
Roth's spots
Kidney abscesses
Brain infarcts

(middle picture of palm) *Janeway lesion*
non-painful hemorrhagic lesions on palms and soles of feet
*essentially diagnostic of bacterial endocarditis

Histology
Inflammation
Bacterial colonies
Staphylococcus aureus
Pseudomonas aeruginosa

12. Which of the following are the mechanisms of left atrial failure in a patient with a mitral stenosis?

Reduced preload, volume overload, and pressure overload

Volume overload, pressure overload, and impaired contractility

Increased preload, increased afterload, and impaired contractility

Increased preload, reduced afterload, and impaired contractility

Left atrial failure in a patient with mitral stenosis can be explained by volume overload, pressure overload, and impaired contractility. Mitral stenosis leads to a narrowing of the mitral valve, which obstructs blood flow from the left atrium to the left ventricle. This obstruction causes an increase in pressure within the left atrium, leading to pressure overload. Additionally, the narrowed valve prevents proper emptying of the left atrium, causing blood to accumulate and leading to volume overload. Finally, the continuous strain on the left atrium can result in impaired contractility, further contributing to left atrial failure.

Explanation

Left atrial failure in a patient with mitral stenosis can be explained by volume overload, pressure overload, and impaired contractility. Mitral stenosis leads to a narrowing of the mitral valve, which obstructs blood flow from the left atrium to the left ventricle. This obstruction causes an increase in pressure within the left atrium, leading to pressure overload. Additionally, the narrowed valve prevents proper emptying of the left atrium, causing blood to accumulate and leading to volume overload. Finally, the continuous strain on the left atrium can result in impaired contractility, further contributing to left atrial failure.

13. In rheumatic Heart Disease which of the following statements would be correct?

There is invariably a preceding Coxsackie viral infection

Mitral stenosis appears early in the clinical progression of the disease

The Right heart is more commonly affected than the left

There has been a recent resurgence of this disease since HIV has become prevalent

Aortic regurgitation & Mitral regurgitation are well recognized sequelae

Rheumatic disease can cause both stenosis and regurge in both valves.
It usually affects the M valve first.

Explanation

Rheumatic disease can cause both stenosis and regurge in both valves.
It usually affects the M valve first.

14. Squatting has which of the following cardiovascular effects?

It has the opposite effect of passive leg raising

It decreases the murmur of mitral regurgitation

It decreases the murmur of ventricular septal defect

It increases the murmur of aortic insufficiency

Squatting increases thoracic pressure, decreasing right to left shunting. Aortic insufficiency (AI), also known as aortic regurgitation (AR), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle.

Explanation

Squatting increases thoracic pressure, decreasing right to left shunting. Aortic insufficiency (AI), also known as aortic regurgitation (AR), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle.